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Question 17-1. What is the purpose of a delegate Question 17-2. Are delegates value types or reference types Question 17-3. Suppose a Phone class has defined an OnPhoneRings delegate. How would you instantiate a delegate called myDelegate to refer to the myMethod method Question 17-4. Define the OnPhoneRings delegate from the preceding question as an event to signal that the phone has rung. Question 17-5. Give an example of how you might call the delegated method from the previous question through the delegate. Question 17-6. What does the event keyword do Question 17-7. How do you pass information into the method that is called through the event Question 17-8. What properties or methods does System.EventArgs have Question 17-9. How can you create delegated methods anonymously Question 17-10. What is returned by a lambda expression

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The easiest screening test for hypercortisolism involves the patient obtaining a salivary cortisol at 11 pm (see below) and then dexamethasone, 1 mg orally, and collecting serum for cortisol determination at about 8 am the next morning; a cortisol level under 5 mcg/dL (< 135 nmol/L, fluorometric assay) or under 2 mcg/dL (< 54 nmol/L, high-performance liquid chromatography [HPLC] assay) excludes Cushing s syndrome with 98% certainty However, 8% of established patients with pituitary Cushing s disease have dexamethasonesuppressed cortisol levels < 2 mcg/dL Therefore, when other clinical criteria suggest hypercortisolism, further evaluation is warranted even in the face of normal dexamethasone-suppressed serum cortisol Antiseizure drugs (eg, phenytoin, phenobarbital, primidone) and rifampin accelerate the metabolism of dexamethasone, in that way causing a lack of cortisol suppression by dexamethasone Estrogens during pregnancy or as oral contraceptives or estrogen replacement therapy may also cause lack of dexamethasone suppressibility Patients with an abnormal dexamethasone suppression test require further investigation, which includes a 24-hour urine collection for free cortisol and creatinine An abnormally high 24-hour urine free cortisol (or free cortisol to creatinine ratio of > 95 mcg cortisol/g creatinine) helps confirm hypercortisolism A misleadingly high urine free cortisol excretion occurs with high fluid intake In pregnancy, urine free cortisol is increased, while 17-hydroxycorticosteroids remain normal and diurnal variability of serum cortisol is

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Once hypercortisolism is confirmed, a plasma ACTH is obtained It must be collected properly in a plastic tube on ice and processed quickly by a laboratory with a reliable, sensitive assay A level of ACTH below about 20 pg/mL indicates a probable adrenal tumor, whereas higher levels are produced by pituitary or ectopic ACTH-secreting tumors

In ACTH-dependent Cushing s syndrome, MRI of the pituitary demonstrates a pituitary lesion in about 50% of cases Premature cerebral atrophy is often noted When the pituitary MRI is normal or shows a tiny irregularity that may be incidental, selective catheterization of the inferior petrosal sinus veins draining the pituitary is performed ACTH levels in the inferior petrosal sinus that are more than twice the simultaneous peripheral venous ACTH levels are indicative of pituitary Cushing s disease Inferior petrosal sinus sampling is also done during CRH administration, which ordinarily causes the ACTH levels in the inferior petrosal sinus to be over three times the peripheral ACTH level when the pituitary is the source of ACTH When inferior petrosal sinus ACTH concentrations are not above the requisite levels, a search for an ectopic source of ACTH is undertaken Location of ectopic sources of ACTH commences with CT scanning of the chest and abdomen, with special attention to the lungs (for carcinoid or small cell carcinomas), the thymus,

the pancreas, and the adrenals In patients with ACTHdependent Cushing s syndrome, chest masses should not be assumed to be the source of ACTH, since opportunistic infections are common, so it is prudent to biopsy a chest mass to confirm the pathologic diagnosis prior to resection CT scanning fails to detect the source of ACTH in about 40% of patients with ectopic ACTH secretion 111In-octreotide scanning is also useful in detecting occult tumors, but 18 FDG-PET scanning is not usually helpful Some ectopic ACTH-secreting tumors elude discovery, necessitating bilateral adrenalectomy In non-ACTH-dependent Cushing s syndrome, a CT scan of the adrenals can localize the adrenal tumor in most cases

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